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Monday, 2 June 2014

E–mail: it starts showing results

Although the health system is advancing very slowly compared to other industries, I'm sure that people are ready to adopt online services and that the health care system is able to open new lines of communication in accordance with the times we live in. Success is guaranteed, provided that the professionals are willing to adapt, and this is the hard part. No wonder the banking offices and travel agencies, to take two examples, have had to redefine, from head to toe, their business models, thanks to or because of online services.

In this review of a scientific evidence program (in the scanned blue cover), the Department of Veterans Affairs in the U.S. asks the following question: What is the association between 'safe' e-mail and clinical outcomes, the patients satisfaction, the treatment adherence and the efficiency or the resource use?

But first, if I may, I’ll clarify the issue of ‘safe’ e-mail because I think it is relevant. For obvious reasons of security and confidentiality, whenever we speak of using electronic messaging to communicate between a patient and their doctor or nurse, one has to do it through a protected access, which for now is the platform of shared clinical record.

Continuing with the question from the Veterans Affairs paper (a review of July 2012), the answer encountered by researchers is that there is “moderate” evidence between the patients’ use of e-mail and the improvements in controlling glycaemia in diabetics, while there is “low” evidence in other circumstances and types of patients, such as the control of hypertension, ulcerative colitis or heart failure.

Therefore, with this evidence, it’s logical that from now on, at least in this post, I may be strict to diabetes, so I present a couple of publications, one a doctoral thesis (2012) by Lynne Harris, which can be found on the University of Washington website and the other is an article in the Health Affairs journal (Zhou 2010) regarding a trial conducted at Kaiser Permanente.

The thesis I consulted in the archives of the University of Washington says that nearly half of U.S. diabetics fail to exercise proper control of their sugar levels. At this point it’s worth being reminded that in Spain, according to a paper published by J. Franch from GEDAPS group, the numbers are clearly better (59% of diabetic patients have an HbA1c less than 7%, see post on March 3rd). Returning to the doctoral thesis, in it we see the type of uses that diabetics make of e-mail, and this is initially relevant data, because everyone speaks of the instrument, but almost nothing is known about how it is working in the few places where it has been implemented.

The thesis’ results say that only a third of the diabetics who have access to e-mail use it, although most users have shown a modest level of use: 1-3 messages per year, combined with a slightly higher number of face to face visits. The more active patients tend to be the ones in the clinically complex range. The thesis demonstrates that the use of e-mail improves glycaemia control measured in HbA1c.

This Health Affairs article explains how a group of Kaiser Permanente researchers designed a study involving 35,423 patients with diabetes, hypertension, or both, and were able to show that the use of e-mail between patients and doctors over a period of 2 months was associated, in a statistically significant way, with improvements in clinical effectiveness, with 2.0% to 6.5% better levels of HbA1c, cholesterol and blood pressure. The same principal investigator (Zhou 2007) had shown 3 years previously that the use of e-mail reduces the number of physical visits between 7 and 10%.

Discussion

Communication technologies are here to stay, I mean in our society in general and, as you know, I continue to talk about society when I say that when these technologies penetrate a business network, they change it drastically. Despite this, all we're seeing is that the progress of these technologies in the health sector is rather limited.

I think, however, that the medical model based on care levels and medical specialties as we know it now, cannot continue like this for long, it will have to be rethought. But consider if it is not rethought (due to laziness or resistance). What could happen? Well, no doubt that if there are no changes from within, the combined pressure of the new epidemiology (chronic and fragile) added to the communication technologies will be responsible for opening all kinds of loopholes in the system.

To summarise: despite the poor results we see when we look at the opening of new communication channels between patients and professionals, we must be wary of this: we advance or we’ll be overtaken.